The Medicare “Billing Bible” Changes Claims Processing Instructions for PAs, NPs, CNSs, CPs, and CSWs

Chapter 12 of the “Medicare Claims Processing Manual” (Medicare Billing Bible) is about to change to reflect deleted and/or corrected information as it relates  to Claims Processing Instructions for Non-Physician Practitioners (NPPs), i.e., Physicians Assistants (PAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), Clinical Psychologists (CPs), and Clinical Social Workers (CSWs) submitting claims to Medicare contractors (carriers and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.

Sample Medicare Card

These changes are effective February 19, 2013.

Key manual revisions/updates are as follows:

  • NPP assistant-at-surgery services should be billed with the “AS” modifier only.
  • The health professional shortage area (HPSA) payment modifiers, “QB” and “QU” have been eliminated because they are no longer valid.
  • The “AH” modifier for CPs and, the “AJ” modifier for CSWs have been eliminated because they are no longer necessary for identification purposes.
  • The correct payment amount for the professional services of PAs, NPs and CNSs is 80 percent of the lesser of the actual charge or, 85 percent of what a physician is paid under the Medicare Physician Fee Schedule (MPFS.)
  • Additionally, the correct payment amount for assistant-at-surgery services furnished by PAs, NPs and CNSs is 80 percent of the lesser of the actual charge or, 85 percent of 16 percent of what a physician is paid under the MPFS for surgical services.
  • Procedures billed with the assistant-at-surgery physician modifiers -80, -81, -82, or the AS modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-at-surgery policy. Accordingly, Medicare will pay claims for procedures with these modifiers only if the services of an assistant-at-surgery are authorized.
  •  Medicare’s policies on billing patients in excess of the Medicare allowed amount apply to assistant-at-surgery services.
  • When a PA, NP, or CNS furnishes services to a patient during a global surgical period, Medicare contractors shall determine the level of PA, NP, or CNS involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice for processing such claims.
  • Billing requirements and adjudication of claims requirements for global surgeries are under chapter 12, sections 40.2 and 40.4 of the “Medicare Claims Processing Manual.”
  • PAs, NPs, and CNSs must have their own “non-physician practitioner” national provider identification number (NPI) number. This NPI is used for identification purposes only when billing for PA, NP, or CNS services, because only an appropriate PA, NP, or CNS employer or, a provider/supplier for whom the PA, NP, or CNS furnishes services as an independent contractor can bill for PA, NP, or CNS services. Specialty code 97 applies for PAs enrolled in Medicare. NPs enrolling in Medicare use specialty code 50 and CNSs use specialty code 89.

Posted in: Collections, Billing & Coding, Medicare & Reimbursement

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6 Comments

  1. Craig Baumgartner PA-C January 7, 2013

    Useful information! Thank You.

  2. Mary Pat Whaley January 8, 2013

    Hi Craig,

    Thanks for stopping by!

    Best wishes,

    Mary Pat

  3. Jan Wyder January 23, 2013

    Mary Pat,
    Curious of your thoughts/teaching on the role of IV home infusion in the changing world of health care delivery. Obviously we specialize in a comprehensive line of home infusion therapies, and am intrigued by what your approach would be to educating physicians and hospitals on how to
    maximize this type of medical care for complex cases, suitable and stable to be out of the hospital.thanks,Jan

  4. Mary Pat Whaley February 3, 2013

    Hi Jan,

    I think the demand for home infusion will continue to grow as the trend away from hospitals and toward care at home/aging at home continues. ACOs may turn to home infusion as one way to reduce costs and increase profits on shared savings.

    One of the ways I would suggest you demonstrate your service to physicians would be to offer one service to a patient the physician would consider home infusion for to see what the patient thinks of it, and for the physician to get feedback from the patient.

    Another possibility is video- everyone loves video! Shoot a video of a real patient getting real home infusion (you could have a short 1-2 minute video and a longer one of 5-6 minutes so people have a choice of the short or long version.) You could email the video, or send physicians a link, do a whole marketing campaign around seeing what it’s like for a patient to get home infusion. I think patients would be interested in seeing it to. So would staff. Most people would like a postcard with an easy link to watch a video. Give it to hospitalists, case managers, discharge planners, pharmacists, healthcare support groups, etc.

    Best wishes,

    Mary Pat

  5. Georgina January 29, 2014

    Does medicare require the NNP to submit assist at surgery claims under the NNP’s NPI number in 24J of the cms 1500 with primary surgeon in Box 31? can a PA ever ‘direct bill’ for assistant at surgery?i’m looking for exact billing requirements of an NNP assistant surgeon but can’t seem to find the answer under the CMS website. could you advise where i could get more info?

  6. Mary Pat Whaley February 4, 2014

    Hi Georgina,

    Here is what Medicare says:

    “Medicare law at section 1833(a)(1)(O) of the Social Security Act authorizes payment for services that a PA furnishes as an assistant-at-surgery. Specifically, when a PA actively assists a physician in performing a surgical procedure and furnishes more than just ancillary services, the PA’s services are eligible for payment as assistant-at-surgery services. For additional policy requirements concerning assistant-at-surgery services furnished by physicians and nonphysician practitioners, see chapter 12, section 20.4.3 of the Medicare Claims Processing Manual, pub. 100-04.

    The contractor shall pay covered PA assistant-at-surgery services at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule. Since physicians are paid at 16 percent of the surgical payment amount under the Medicare Physician Fee Schedule for assistant-at-surgery services, the actual payment amount that PAs receive for assistant-at-surgery services is 13.6 percent of the amount paid to physicians.

    The AS modifier must be reported on the claim form when billing PA assistant-at-surgery services.”

    This is from the Medicare Claims Processing Manual – Chapter 12: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

    Here is the information on completing the 1500: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf

    I hope this is the answer you are looking for.

    Best wishes,

    Mary Pat

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